Government & Medicine

What becomes of the broken hearted?

Post-MI care vacillates wildly across the country. But don't pack your bags for Alberta just yet � the devil's in the details

By Peter Woodford

"The best place to have a heart attack is Alberta," The Globe and Mail proclaimed recently in response to research showing that geography largely determines how quickly heart attack patients get major surgery � if they get it at all. This flying media leap has had the study's authors scrambling to pull in the reins.

The research, conducted by the Canadian Cardiovascular Outcomes Research Team (CCORT) and published in the April issue of the Canadian Journal of Cardiology, looked at regional variations in post-myocardial infarction surgeries as part of their ongoing research into Canada's top killer. The study found that patients in the Maritimes, especially PEI, and Ontario are less likely to get invasive procedures like bypass surgery than patients elsewhere in Canada. At the other end of the spectrum, the study also showed that reaching for the scalpel � like the steak knife � seems to be second nature in Alberta.

So let's all move to Alberta, right? Not so fast, bucko, say the study authors. Invasive procedures aren't the whole story. Previous CCORT studies have shown that other provinces lean more towards drug treatments, and that so-called 'have-not' provinces, along with well-heeled Ontario, are more apt to use statins and other drug therapies. Moreover, CCORT concludes, this parsimonious approach makes some sense.

"Evidence would suggest that drug therapies such as statins have a much greater impact on the net survival rates of heart attack patients in the population than do higher ticket items, such as bypass surgery," says Dr David Alter, one of the study's authors, adding that though revascularization procedures are very beneficial to some patients, they may actually cause harm for others.

The Canadian press mostly spun the story as an access scandal, but Dr Alter cautions that this misses the point. He sees a clear correlation between provincial capacities for these procedures and how many are actually carried out, but warns that we don't yet know the 'right' rate of revascularization.

He also stresses that "interventions must be examined within the context of all available evidence-based therapeutic and lifestyle prevention initiatives, which together will have a much greater impact on survival rates in the population than variations in procedure rates alone."

A QUESTION OF CAPACITY
Lead author Dr Louise Pilote also sees capacity as a central factor in the study's findings. "Availability is key," she says. "There are areas of the country that are lagging behind in terms of availability of cardiac services." She's quite surprised about Ontario's results and pins the blame on "poor organization and also lack of availability outside of Toronto," she says. "I must add that Ontario is currently making great progress in increasing availability to far-out regions."

If you compare an earlier CCORT study's provincial breakdown of cardiovascular disease mortality from 1995 to 1997, Alberta's rate was close to the national average and PEI wasn't too much higher. At that time Albertans were already the most likely to get revascularization procedures; they also did well in recovering from heart attack. "I suspect that better access to procedures is one of several factors that explains this finding," says Dr Jack Tu, a CCORT principal investigator.

Taken in its proper context, the current CCORT study sheds light on other interesting disparities in cardiac care. It also shows that the youngest age group is the most likely to get operated on and that women who've had attacks are across the board less likely to get revascularization proce-dures like percutaneous coronary intervention and coronary artery bypass graft.

Waiting times also get the once-over. For revascularizations, waiting times are trending downward across Canada, but they do remain a cause for concern. Alberta and BC had the lowest average waits at eight and nine days respectively. Overall, the Maritimes and Ontario had the longest waiting times, with Nova Scotia bringing up the rear at 29 days.

But Dr Tu isn't in a hurry to give Alberta or British Columbia proverbial hero sandwiches. "In general, there is no real best place to have a heart attack. It's a life-threatening condition and at least 10% of Canadians will die from it � regardless of where they live in the country."